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Health inequalities: what are they and what works to reduce them? Gerry McCartney Consultant in Public Health & Head of Public Health Observatory NHS Health Scotland

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Of all inequalities, injustice in health is the most shocking and inhumane Martin Luther King

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Health inequalities can be defined as the: “systematic differences in the health of people occupying unequal positions in society” 1 1 Graham H. The challenge of health inequalities, In: Graham H. Understanding health inequalities. Maidenhead: Open University Press, 2009.

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Life expectancy drops by 2.0 years for males and 1.2 years for females for each station on the railway line between Jordanhill and Bridgeton Source: McCartney G. Illustrating Glasgow’s health inequalities. JECH 2010; doi /jech

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Inequality in male life expectancy by local authority, (source: NRS)

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Inequality in female life expectancy by local authority, (source: NRS)

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Inequality in mortality between best and worst 10 % of local authorities in Great Britain (sources: Thomas 2010 and Luxembourg Income Study)

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Inequality in mortality between richest and poorest 5ths of the US population (sources: Krieger 2008 and Luxembourg Income Study)

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Health inequalities are wide and growing in Scotland They account for about 5,000 additional deaths/year They have grown quickly over the last 40 years They are much narrower in other places and have been narrower here in the past Summary so far…

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Artefact Undermined by inequalities demonstrated using different statistical measures of social status …and in different places and different times Very difficult to sustain a theory that such outcomes are unrelated to social status However, improved measures of social status, or, perhaps better, of the social realities of people’s ‘lived experience’, would still be helpful

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Unhealthy behaviours are more prevalent in lower socio-economic groups, however: The same behaviours generate higher mortality amongst working class It ignores why particular social groups adopt unhealthy behaviours 1 2 The patterning of health behaviours is explained by socio-economic circumstances Where unhealthy behaviours have equalised, mortality inequalities have not 3 Changes over time in the causes of death responsible for inequalities suggest that removing one particular exposure (e.g. unclean drinking water) only changes one high cause-specific mortality rate for another Nettle D. Social class through the evolutionary lens. The Psychologist 2009; 22(11): Lynch JW, Kaplan GA, Salonen JT. Why do poor people behave poorly? Variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic lifecourse. Social Science and Medicine 1997; 44(6): Stringhini S, Dugravot A, Shipley M, Goldberg M, Zins M, Kivima M, Marmot M, Sabia S, Singh-Manoux A. Health Behaviours, Socioeconomic Status, and Mortality: Further Analyses of the British Whitehall II and the French GAZEL Prospective Cohorts. PLoS Med 2011; 8(2): e doi: /journal.pmed Link BG, Phelan J. McKeown and the idea that social conditions are fundamental causes of disease. American Journal of Public Health 2002; 92(5): Mackenbach JP. What would happen to health inequalities if smoking were eliminated? BMJ 2011; 342: d3460.

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Structural and political economy Differences in income, resources and power between groups cause health inequalities: Health inequalities rise and fall with income inequalities The health of communities has improved when they have been given more resources by chance 1 Those with most resources are always the healthiest, regardless of their behaviours 2 Even when genetic factors are involved (such as cystic fibrosis) inequalities in mortality by social class are wide and vary depending on changing contextual factors 3 1 Costello EJ, Compton SN, Keeler G, Angoid A. Relationships between poverty and psychopathology. JAMA 2003; 290: Commission on Social Determinants of Health Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization. 3 Barr HL, Britton J, Smyth AR, Fogarty AW. Association between socioeconomic status, sex, and age at death from cystic fibrosis in England and Wales (1959 to 2008): cross sectional study. BMJ 2011; 343: d4662.

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Structural explanations fit best Behavioural and cultural theories are relevant, but insufficient. Blaming poor people for their behaviours, skills and cultures is damaging Selection theory doesn’t explain much Therefore health inequalities are determined by political decisions and political priorities Health inequalities are not inevitable and have been reduced in the past and in other places Summary so far…

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Least likely actions to reduce health inequalities Information based campaigns (mass media information campaigns) Written materials (pamphlets, food labelling) Campaigns reliant on people taking the initiative to opt in Campaigns/messages designed for the whole population Whole school health education approaches (e.g. school based anti-smoking and alcohol programmes) Approaches which involve significant price or other barriers Housing or regeneration programmes that raise housing costs

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My organisation does this already… If so – great! But, are you sure? How do you know? Support is available (e.g. Evaluation Support Scotland) High quality evaluation is essential if good practice is to be spread and if we are to improve what we all do

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Conclusions Health is worse and improving more slowly in Scotland compared to the rest of Europe Health inequalities are large and increasing Policies and politics are the causes of health inequalities: behaviour and culture are only partial explanations More equitable distribution of income, power and wealth is paramount Regulation, taxation and structural changes to the socio- economic environment are also likely to help, as is intensive support for those most in need Health inequalities are not inevitable and can be reduced

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Thank you for listening/heckling* *delete as appropriate Contact me at

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A fairer, healthier Scotland: a way forward together #G2014

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A Fairer, Healthier Scotland and World Wednesday 19 th February 2014

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Overview of Presentation Introduce Healthy n Happy A brief musical interlude A PLEA What we do and how we do it

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History and operating environment Raison dêtre and Vision: Cambuslang and Rutherglen will be the healthiest and happiest places to live in Scotland Best in our field in Scotland An excellent employer Connector/The Glue

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Anyone for a spot of selfish capitalism?Why don’t poor people go grouse shooting? Eighty-five people control the same amount of wealth (about $110 trillion) as the bottom half of the world's population. That is 85 people compared with 3.5 billion Oxfam "The cancer burden is growing at an alarming pace and emphasizes the need for urgent implementation of efficient prevention strategies to curb the disease," WHO “Also, 2.4 million people in the UK are among the wealthiest 1% in the world”. Credit Suisse Global Wealth Report 2013 ‘Record rise in insulin use as experts say Britain needs a wake-up call over growing obesity epidemic’ All media platforms 06/02/14 According to the list, the 1,000 richest people in Britain have wealth totalling almost £450 billion. The number of billionaires in the UK has increased ten-fold since the Sunday Times Rich List was first published in 1989, shooting from nine to 88. There were 77 last year Sunday Times Rich List. Predictions that half the British population will be obese by 2050 ''underestimate'' the scale of the obesity crisis.... The ''doomsday scenario'' set out in the report does not cover the true extent of the problem” National Obesity Forum MY BLOOD PRESSURE IS RISING....WHAT ABOUT YOURS???

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What we do and how we do it in 3 easy steps: Services and service design processes The (boring?) but vital bit behind it all: Strategy, Culture, Values, Quality The most important bit (that nobody really wants to pay for): Connecting and facilitating

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Connecting and Facilitating Connecting people and communities to policy and planning Scottish Communities for Health and Wellbeing Some excellent examples: Bike Town and Burnhill

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Bike Town Bringing people and communities together, improving health, wellbeing and environment, and maximising economic potential through supporting and developing cycling across Cambuslang & Rutherglen

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What are the key characteristics that support good practice in collaborative practice on health inequalities? What have been the barriers to developing good practice and how have you addressed these? What key lessons would you ask Conference to share with others? Facilitated table discussion